Randomized, controlled trial of coronary artery bypass surgery versus percutaneous coronary intervention in patients with multivessel coronary artery disease: six-year follow-up from the Stent or Surgery Trial (SoS)

Is There Still a Survival Advantage to Bypass Surgery Over Percutaneous Intervention in the Modern Era?

The method of revascularization for multi-vessel coronary artery disease (MVD) has traditionally been coronary artery bypass grafting (CABG), however, due to recent advances in the field of percutaneous coronary intervention (PCI), this latter technique has gained in popularity and its role in guidelines has been promoted. This review aims to address the current data available for the treatment of patients with complex coronary disease, including the specific disease subset in those with diabetes mellitus, focusing on the importance of risk stratification and review by the 'Heart Team'. The concept of complete versus incomplete revascularization and the assessment of lesions utilizing functional techniques are discussed. Over recent years, PCI has grown to become the most frequently performed therapeutic intervention in medicine and continues to grow. There are encouraging data that this is an effective and safe treatment option in selected patients, however, neither strategy alone can provide a solution for the entire spectrum of patients with MVD.

Analysis of the bypass angioplasty revascularization investigation trial using a multistate model of clinical outcomes

Current cardiovascular randomized trials typically use composite outcomes. We hypothesized that the Bypass Angioplasty Revascularization Investigation (BARI) outcomes and conclusions would differ using a multistate model relative to the intervention for the composite outcome of death (D) and nonfatal Q-wave myocardial infarction (MI). We used a multistate model which uses transition paths to simultaneously assess multiple end points. Using the 10-year follow-up BARI data, we post hoc analyzed outcomes according to 3 transition paths: (1) from intervention to MI; (2) from intervention to death; and (3) from MI to death. Of 1,829 patients randomized to the intervention of percutaneous transluminal coronary angioplasty or coronary artery bypass grafting (CABG), 700 (38%) experienced the composite event D/MI which included 230 (13%) nonfatal MI and 470 (26%) death without antecedent nonfatal MI, whereas 79 of 230 (34%) experienced death after nonfatal MI. Outcomes of the 3 individual transition paths were analyzed by a multistate model. In contrast to standard survival analyses, after adjustment for baseline clinical covariates, outcomes after percutaneous transluminal coronary angioplasty or CABG were not significantly different for intervention to MI (p = 0.33) or intervention to death (p = 0.23), but MI to death favored CABG (p = 0.02). Deconstruction of the BARI data using a multistate model identifies a significant difference in individual transition-stage outcomes and therefore trial conclusions in contrast to the standard methods of survival analysis. These observations suggest multistate models should be considered in the design and analysis of randomized cardiovascular trials which use composite outcomes.

Comparison of coronary artery bypass graft surgery and percutaneous coronary intervention in patients with diabetes

OPINION STATEMENT

The optimal revascularization strategy in patients with diabetes is controversial. The Bypass Angioplasty Revascularization Investigation (BARI) trial, done more than a decade ago, suggested a mortality benefit of coronary artery bypass graft surgery (CABG) when compared with percutaneous coronary intervention (PCI) (with plain old balloon angioplasty) in the subgroup of patients with diabetes. In addition, several observational studies and meta-analyses similarly suggest a benefit of CABG over PCI in patients with diabetes. However, most of these studies compared CABG with PCI using balloon angioplasty, bare metal stents, or first-generation drug-eluting stents. In this review, we critically examine the data for optimal revascularization strategy in patients with diabetes and ask the question whether the currently available data from randomized trials that used outdated stents are applicable to current day practice.

Comparison of percutaneous coronary intervention with drug eluting stents versus coronary artery bypass grafting in patients with multivessel coronary artery disease: Meta-analysis of six randomized controlled trials

OBJECTIVE

To compare outcomes of percutaneous coronary intervention (PCI) with drug eluting stent (DES) and Coronary Artery Bypass Grafting (CABG) in patients with multivessel Coronary Artery Disease (CAD) using data from randomized controlled trials (RCT).

BACKGROUND

PCI and CABG are established strategies for coronary revascularization in the setting of ischemic heart disease. Multiple RCTs have compared outcomes of the two modalities in patients with multivessel CAD.

METHODS

We did a meta-analysis from six RCTs in the contemporary era comparing the effectiveness of PCI with DES to at 1 year, 2 years and 5 years respectively.

RESULTS

Compared to CABG, at one year PCI was associated with a significantly higher incidence of TVR (RR=2.31; 95% CI: [1.80-2.96]; P=<0.0001), lower incidence of stroke (RR=0.35; 95% CI: [0.19-0.62]; P=0.0003), and no difference in death (RR=1.02; 95% CI: [0.77-1.36]; P=0.88) or MI (RR=1.16; 95% CI: [0.72-1.88]; P=0.53). At 5 years, PCI was associated with a higher incidence of death (RR=1.3; 95% CI: [1.10-1.54]; P=0.0026) and MI (RR=2.21; 95% CI: [1.75-2.79]; P=<0.0001). While the higher incidence of MI with PCI was noticed in both diabetic and non-diabetics, death was increased mainly in diabetic patients.

CONCLUSION

In patients with multi-vessel CAD, PCI with DES is associated with no significant difference in death or MI at 1 or 2 years. However at 5 years, PCI is associated with higher incidence of death and MI.

[Percutaneous coronary intervention versus bypass surgery in patients with diabetes and multivessel coronary disease. Coronary revascularization after FREEDOM]

Is coronary revascularization required in a patient with chronic stable coronary artery disease or can optimized medical therapy (OMT) alone be a sufficient alternative? This question has been controversially discussed for non-diabetics as well as for diabetics since the COURAGE and BARI 2D trials. According to our present knowledge, a patient will benefit from coronary revascularization only when either a non-invasive test method, such as single photon emission computed tomography (SPECT) or positron emission tomography (PET) myocardial scintigraphy, stress echocardiography or stress nuclear magnetic resonance imaging, can detect relevant, objective evidence of ischemia >10% of the left ventricular myocardium or when a pathological fractional flow reserve (FFR) <0.80 can be measured in an invasive procedure for an angiographically detectable coronary stenosis. If similar relevant ischemia can be non-invasively or invasively objectified in a patient with chronic stable multivessel coronary artery disease, the often controversially discussed question arises particularly in diabetics whether a percutaneous coronary intervention (PCI) with implantation of drug-eluting stents or coronary artery bypass surgery should be favored. The FREEDOM study (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease), published in November 2012, was the first prospective randomized study to examine this issue in diabetic patients with multivessel coronary artery disease. Despite a higher rate of stroke in the surgical cohort, after an average follow-up time of 3.8 years a significant prognostic advantage in favor of bypass surgery was detected for a combined primary endpoint of all-cause mortality, nonfatal myocardial infarction and nonfatal stroke. Thus, in the new ESC guidelines on diabetes, pre-diabetes and cardiovascular diseases developed with the EASD of the European Society of Cardiology and published in 2013, coronary bypass surgery has a class I, level of evidence A recommendation for patients with diabetes mellitus, chronic stable multivessel coronary disease and a synergy between PCI with taxus and cardiac surgery (SYNTAX) score >22. The decision for or against a PCI/stent implantation or coronary bypass surgery in a diabetic patient with chronic stable multivessel coronary artery disease should therefore be made with the patient only after a detailed informed consent discussion and comprehensive explanation of both treatment options. In controversial cases, particularly with an equivocal SYNTAX score around 22, relevant comorbidities or anticipated method-specific complications, a one-stage ad hoc intervention during the diagnostic coronary angiography should be rejected in favor of a two-stage procedure with prior discussion of both treatment options in the heart team comprising noninvasive cardiologists, interventional cardiologists and cardiac surgeons.

Coronary artery bypass surgery or coronary stenting in diabetic patients: too soon to make a statement?

Diabetic patients have been associated with poor procedural and long term outcome if they were treated either with percutaneous coronary interventions or coronary artery bypass surgery. Recently several randomized clinical trials (RCT) in this subset of patients have been published showing a greater incidence of major adverse cardiovascular events, death/myocardial infarction/stroke, if they were treated with first generation drug eluting stents (DES) which was not observed previously in the bare metal stent era. However, almost simultaneously with this data, several RCT demonstrated better safety profile with new generation DES including biocompatible polymers, biodegradable polymers and lately complete absorbable DES, all of them showed reduction in adverse cardiac events compared to 1st generation DES in patients with diabetes. In this editorial we review the old and new randomized data in diabetic patients and conclude that there are many unresolved issues to make a definitive statement regarding which is the best revascularization preference in diabetic patients and the measured final efficacy of PCI and CABG will not be reached until the arrival of RCT using next generation DES, including complete absorbable scaffolds.

The management of acute coronary syndromes in patients with chronic kidney disease

Coronary heart disease is highly prevalent in patients with CKD, and survival after acute coronary syndrome (ACS) is worse compared with the general population. Many trials that define guidelines for cardiovascular disease excluded patients with kidney disease, leaving a gap between the evidence base and clinical reality. The underlying pathophysiology of vascular disease appears to be different in the setting of CKD. Patients with CKD are more likely to present with myocardial infarction and less likely to be diagnosed with ACS on admission compared with the general population. Patients with CKD appear to benefit with angiography and revascularization compared with medical management alone. However, the increased risk of in-hospital bleeding and risk of contrast-induced acute kidney injury are 2 factors that can limit overall benefit for some. Thus, judicious application of available therapies for the management of ACS is warranted to extend survival and reduce hospitalizations in this high-risk population. In this review, we highlight the clinical challenges and potential solutions for managing ACS in patients with CKD.

Percutaneous coronary invervention versus coronary artery bypass grafting: a meta-analysis

OBJECTIVE

To compare the effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with coronary artery disease.

METHODS

MEDLINE, Embase, and Cochrane Central were searched, and randomized controlled trials were included. Outcomes were assessed at maximum available follow-up.

RESULTS

This meta-analysis includes 31 trials with 15,004 patients. As regards death, more patients died after PCI compared with CABG across all types of patients (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0-1.3; P = .05) as well as in patients with multivessel disease (OR, 1.2; 95% CI, 1.0-1.4; P = .02) or diabetes (OR, 1.6; 95% CI, 1.2-2.1; P < .01). Myocardial infarction occurred as frequently after PCI (OR, 1.2; 95% CI, 0.9-1.5; P = .28). Repeat revascularization was more common after PCI (OR, 4.5; 95% CI, 3.5-5.8; P < .01), with a progressive decline in ORs from the pre-stent era (OR, 7.0; 95% CI, 5.1-9.7; P < .01), to the bare metal stent era (OR, 4.5; 95% CI, 3.6-5.5; P < .01), and to the drug-eluting stent era (OR, 2.5; 95% CI, 1.8-3.4; P < .01). Stroke was more common after CABG (OR, 0.7; 95% CI, 0.5-0.9; P = .01).

CONCLUSIONS

Compared with PCI, CABG had a lower risk of death in multivessel disease or diabetes patients eligible for either intervention, a lower risk of repeat revascularization, but a higher risk of stroke.

Surgical versus percutaneous revascularization in patients with multivessel coronary artery disease

New-generation stents have been continually developed in order to improve the safety and efficacy of percutaneous coronary intervention (PCI). Several randomized clinical trials have been conducted over the last two decades to compare the outcomes of PCI with coronary artery bypass grafting (CABG), which has been the time-tested treatment of multivessel coronary artery disease. The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial is one of the most recent and largest randomized controlled trials comparing PCI using the paclitaxel-eluting first-generation stent with CABG and was uniquely formulated to represent "real world" daily practice. The final 5-year main results of this trial and its various prespecified subgroups have been published in the past year. These results will form the basis of the new guidelines that will be published in the near future. This review is a compilation of the results of the SYNTAX trial and comparisons with other contemporary trials, meta-analyses, and retrospective studies of large registries and how these results help cardiac surgeons and cardiologists in judicious decision-making for their patients with multivessel coronary artery disease requiring revascularization.

Comparative effectiveness of revascularization strategies in stable ischemic heart disease: current perspective and literature review

Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are established strategies for coronary revascularization in the setting of ischemic heart disease. Multiple randomized controlled trials and observational studies have compared the impact of the two modalities on the patients' quality of life, mortality and morbidity, as well as the cost-effectiveness of these modalities in different clinical setting. CABG is the preferred strategy for revascularizations in patients with multi-vessel disease, especially in those with higher risk secondary to associated diabetes, left ventricular dysfunction or more complex lesions. PCI is a reasonable revascularization modality in patients with ischemia and single or low-risk multi-vessel disease and those with unprotected left main with low complexity anatomy. Compared with PCI, CABG is associated with less repeat revascularization, better quality of life and improved survival in high-risk patients. Although CABG is associated with higher cost, it is probably associated with a reasonable cost per quality-adjusted life-year gained in many patients. Therefore, CABG will often be a cost-effective strategy, especially in patients with high angiographic complexity and/or diabetes.

Identification of key genes and crucial modules associated with coronary artery disease by bioinformatics analysis

The aim of this study was to identify key genes associated with coronary artery disease (CAD) and to explore the related signaling pathways. Gene expression profiles of 110 CAD and 112 non-CAD, healthy patients [CAD index (CADi) >23 and =0, respectively] were downloaded from the Gene Expression Omnibus (GEO) database (accession: GSE12288). The differentially expressed genes (DEGs) in CAD were identified using t-tests, and protein-protein interaction (PPI) networks for these DEGs were constructed using the Search Tool for the Retrieval of InteractiNg Genes (STRING) database. The Database for Annotation, Visualization and Integrated Discovery (DAVID) tool was used to identify potentially enriched biological processes (BP) among the DEGs using Gene Ontology (GO) terms, and to identify the related pathways using the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway database. In addition, expression-activated subnetworks (crucial modules) of the constructed PPI networks were identified using the jActiveModule plug-in, and their topological properties were analyzed using NetworkAnalyzer, both available from Cytoscape. The patient specimens were classified as grade I, II and III based on CADi values. There were 151 DEGs in grade I, 362 in grade II and 425 in grade III. In the PPI network, the gene GRB2, encoding the growth factor receptor-bound protein 2, was the only common DEG among the three grades. In addition, 10 crucial modules were identified in the PPIs, 4 of which showed significant enrichment for GO BP terms. In the 12 nodes with the highest betweenness centrality, we found two genes, encoding GRB2 and the heat shock 70 kDa protein 8 (HSPA8). Moreover, the chemokine and focal adhesion signaling pathways were selected based on their relative abundance in CAD. The GRB2 and HSPA8 proteins, as well as the chemokine and focal adhension signaling pathways, might therefore be critical for the development of CAD.

Composite outcomes in coronary bypass surgery versus percutaneous intervention

BACKGROUND

Recent observational studies show that patients with multivessel coronary disease have a long-term survival advantage with coronary artery bypass grafting (CABG) compared with percutaneous coronary intervention (PCI). Important nonfatal outcomes may also affect optimal treatment recommendation.

METHODS

CABG was compared with percutaneous catheter intervention by using a composite of death, myocardial infarction (MI), or stroke. Medicare patients undergoing revascularization for stable multivessel coronary disease from 2004 through 2008 were identified in national registries. Short-term clinical information from the registries was linked to Medicare data to obtain long-term follow-up out to 4 years from the time of the procedure. Propensity scoring with inverse probability weighting was used to adjust for baseline risk factors.

RESULTS

There were 86,244 CABG and 103,549 PCI patients. The mean age was 74 years, with a median 2.67 years of follow-up. At 4 years, the propensity-adjusted adjusted cumulative incidence of MI was 3.2% in CABG compared with 6.6% in PCI (risk ratio, 0.49; 95% confidence interval, 0.45 to 0.53). At 4 years, the cumulative incidence of stroke was 4.5% in CABG compared with 3.1% in PCI patients (risk ratio, 1.43; 95% confidence interval, 1.31 to 1.54). This difference was primarily due to the higher 30-day stroke rate for CABG (1.55% vs 0.37%). For the composite of death, MI, or stroke, the 4-year adjusted cumulative incidence was 21.6% for CABG and 26.7% for PCI (risk ratio, 0.81; 95% confidence interval, 0.78 to 0.83).

CONCLUSIONS

The 4-year composite event rate of death, MI, and stroke favored CABG, whereas the risk of stroke alone favored PCI.

Comparison of intermediate-term outcomes of coronary artery bypass grafting versus drug-eluting stents for patients ≥75 years of age

Several randomized controlled trials and observational studies have compared outcomes of percutaneous coronary interventions (PCIs) with drug-eluting stents (DESs) and coronary artery bypass grafting (CABG), but they have not thoroughly investigated the relative difference in outcomes for patients aged ≥75 years. In this study, a total of 3,864 patients receiving DES and CABG (1,932 CABG-DES pairs) with multivessel coronary disease were propensity matched using multiple patient risk factors and were compared with respect to 3 outcomes (mortality, stroke/myocardial infarction [MI]/mortality, and repeat revascularization) at 2.5 years with a mean follow-up of 18 months. The mortality rates (DES/CABG hazard ratio 1.06, 95% confidence interval 0.87 to 1.30) and the stroke/MI/mortality rates (DES/CABG hazard ratio 1.15, 95% confidence interval 0.97 to 1.38) for the 2 procedures were not significantly different. Repeat revascularization rates were significantly higher for patients who received DESs. In conclusion, older patients experienced similar mortality and stroke/MI/mortality rates for CABG and PCI with DES, although repeat revascularization rates were higher for patients undergoing PCI with DES.

Randomized trials of PCIs versus CABG surgery: why coronary stenting should remain the first choice of revascularization in non-diabetic patients and why the controversy is still present in diabetics

Knowing the best revascularization option for diabetic patients with multiple vessel disease is a challenge without a definitive answer. There have been several randomized clinical trials and subsequent meta-analyses comparing current available technology trying to reach an exhaustive conclusion; comparisons between coronary artery bypass grafts and bare-metal stents, coronary artery bypass grafts and first generation drug-eluting stents and, most recently, first generation versus latest generation drug-eluting stents generated some interesting results. Information provided by pooled data from some of the most important randomized clinical cardiology trials from the last two decades have produced surprising results. The authors analyze these data to discuss the best therapeutic procedures for each patient.

Comparison of coronary artery bypass surgery and percutaneous coronary intervention in patients with diabetes: a meta-analysis of randomised controlled trials

BACKGROUND

The choice between coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) for revascularisation in patients with diabetes and multivessel coronary artery disease, who account for 25% of revascularisation procedures, is much debated. We aimed to assess whether all-cause mortality differed between patients with diabetes who had CABG or PCI by doing a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing CABG with PCI in the modern stent era.

METHODS

We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials from Jan 1, 1980, to March 12, 2013, for studies reported in English. Eligible studies were those in which investigators enrolled adult patients with diabetes and multivessel coronary artery disease, randomised them to CABG (with arterial conduits in at least 80% of participants) or PCI (with stents in at least 80% of participants), and reported outcomes separately in patients with diabetes, with a minimum of 12 months of follow-up. We used random-effects models to calculate risk ratios (RR) and 95% CIs for pooled data. We assessed heterogeneity using I(2). The primary outcome was all-cause mortality in patients with diabetes who had CABG compared with those who had PCI at 5-year (or longest) follow-up.

FINDINGS

The initial search strategy identified 3414 citations, of which eight trials were eligible. These eight trials included 7468 participants, of whom 3612 had diabetes. Four of the RCTs used bare metal stents (BMS; ERACI II, ARTS, SoS, MASS II) and four used drug-eluting stents (DES; FREEDOM, SYNTAX, VA CARDS, CARDia). At mean or median 5-year (or longest) follow-up, individuals with diabetes allocated to CABG had lower all-cause mortality than did those allocated to PCI (RR 0.67, 95% CI 0.52-0.86; p=0.002; I(2)=25%; 3131 patients, eight trials). Treatment effects in individuals without diabetes showed no mortality benefit (1.03, 0.77-1.37; p=0.78; I(2)=46%; 3790 patients, five trials; p interaction=0.03). We identified no differences in outcome whether PCI was done with BMS or DES. When present, we identified no clear causes of heterogeneity.

INTERPRETATION

In the modern era of stenting and optimum medical therapy, revascularisation of patients with diabetes and multivessel disease by CABG decreases long-term mortality by about a third compared with PCI using either BMS or DES. CABG should be strongly considered for these patients.

Revascularization strategies in patients with Type 2 diabetes mellitus

This review aims to describe new developments in coronary revascularization strategies for patients with pre-existing Type 2 diabetes mellitus (DM). Recommended strategies for revascularization have been an active area of study with recent important developments. In patients with Type 2 DM and multivessel coronary artery disease (CAD), coronary artery bypass graft (CABG) surgery is the preferred method for revascularization. Patients with DM are at increased risk for diffuse cardiovascular disease due to the proinflammatory, prothrombotic effects of chronic hyperglycemia. In patients undergoing percutaneous coronary intervention, drug-eluting stents and more potent antiplatelet agents especially in those presenting with acute coronary syndromes should be employed.

Survival prediction models for coronary intervention: strategic decision support

BACKGROUND

For a given patient with coronary artery disease, it is uncertain which therapy, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), maximizes long-term survival. Hence, we developed survival models for CABG and PCI using bare-metal stents (BMS) or drug-eluting stents (DES), programmed a decision-support tool, and identified its potential usefulness.

METHODS

From 1995 to 2007, 23,182 patients underwent primary isolated CABG (n=13,114) or first-time PCI with BMS (n=6,964) or DES (n=3,104). Follow-up was 6.3±3.9 years. Survival models were developed independently for each therapy, then all factors appearing in any of the three models were forced into a final model for each. These were programmed into a decision-support tool. Predicted differences in 5-year survival for the same patient among the three therapies were calculated.

RESULTS

Unadjusted survival was 96%, 86%, and 68% at 1, 5, and 10 years after CABG, 94%, 83%, and 68% after BMS, and 95% and 84% (no 10-year estimate) after DES, respectively. Risk factors for early and mid-term mortality were identified, leading to variable-rich (25 variables) prediction models. Patients most likely to experience a 5-year survival benefit from DES were those undergoing emergency revascularization for acute infarction, and patients most likely to benefit from CABG had extensive coronary artery disease and numerous comorbidities.

CONCLUSIONS

Detailed prediction models for prognosis after PCI and CABG are useful for developing a clinically relevant, strategic decision-support tool that reveals who may experience a long-term survival benefit from each modality.

Comparative effectiveness of multivessel coronary bypass surgery and multivessel percutaneous coronary intervention: a cohort study

BACKGROUND

Randomized trials of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) suggest that patient characteristics modify the effect of treatment on mortality.

OBJECTIVE

To assess whether clinical characteristics modify the comparative effectiveness of CABG versus PCI in an unselected, general patient population.

DESIGN

Observational treatment comparison using propensity score matching and Cox proportional hazards models.

SETTING

United States, 1992 to 2008.

PATIENTS

Medicare beneficiaries aged 66 years or older.

INTERVENTION

Multivessel CABG or multivessel PCI.

MEASUREMENTS

The CABG-PCI hazard ratio (HR) for all-cause mortality, with prespecified treatment-by-covariate interaction tests, and the absolute difference in life-years of survival in clinical subgroups after CABG or PCI, both over 5 years of follow-up.

RESULTS

Among 105 156 propensity score-matched patients, CABG was associated with lower mortality than PCI (HR, 0.92 [95% CI, 0.90 to 0.95]; P < 0.001). Association of CABG with lower mortality was significantly greater (interaction P ≤ 0.002 for each) among patients with diabetes (HR, 0.88), a history of tobacco use (HR, 0.82), heart failure (HR, 0.84), and peripheral arterial disease (HR, 0.85). The overall predicted difference in survival between CABG and PCI treatment over 5 years was 0.053 life-years (range, -0.017 to 0.579 life-years). Patients with diabetes, heart failure, peripheral arterial disease, or tobacco use had the largest predicted differences in survival after CABG, whereas those with none of these factors had slightly better survival after PCI.

LIMITATION

Treatments were chosen by patients and physicians rather than being randomly assigned.

CONCLUSION

Multivessel CABG is associated with lower long-term mortality than multivessel PCI in the community setting. This association is substantially modified by patient characteristics, with improvement in survival concentrated among patients with diabetes, tobacco use, heart failure, or peripheral arterial disease.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute.

Percutaneous versus surgical interventions for coronary artery disease in those with diabetes mellitus

Diabetes mellitus (DM) is a metabolic disorder of multiple etiologies that causes long-term damage of various organs including the cardiovascular system. A consistent observation shows that DM amplifies the risk of cardiovascular events by 4- to 6-fold. Since coronary artery disease (CAD) in diabetic patients exhibits diffuse and accelerated lesions, invasive revascularization continues to be a challenge and has worse outcomes than patients without DM. Owing to the pathogenesis of DM and the presence of severe endothelial dysfunction, investigators have been trying to find new treatment modalities that could target the treatment of the disease rather than the treatment of the lesion. Until new treatment modalities are proven and gain acceptance, invasive revascularization remains to be the choice of treatment in such patients. The focus of this review is to compare the results of percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for the treatment of stable CAD in patients with DM.

Comparative effectiveness of coronary artery bypass grafting and percutaneous coronary intervention for multivessel coronary disease in a community-based population with chronic kidney disease

BACKGROUND

Randomized clinical trials comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) have largely excluded patients with chronic kidney disease (CKD), leading to uncertainty about the optimal coronary revascularization strategy. We sought to test the hypothesis that an initial strategy of CABG would be associated with lower risks of long-term mortality and cardiovascular morbidity compared with PCI for the treatment of multivessel coronary heart disease in the setting of CKD.

METHODS

We created a propensity score-matched cohort of patients aged ≥30 years with no prior dialysis or renal transplant who received multivessel coronary revascularization between 1996 and 2008 within a large integrated health care delivery system in northern California. We used extended Cox regression to examine death from any cause, acute coronary syndrome, and repeat revascularization.

RESULTS

Coronary artery bypass grafting was associated with a significantly lower adjusted rate of death than PCI across all strata of estimated glomerular filtration rate (eGFR) (in mL/min per 1.73 m(2)): the adjusted hazard ratio (HR) was 0.81, 95% CI 0.68 to 1.00 for patients with eGFR ≥60; HR 0.73 (CI 0.56-0.95) for eGFR of 45 to 59; and HR 0.87 (CI 0.67-1.14) for eGFR <45. Coronary artery bypass grafting was also associated with significantly lower rates of acute coronary syndrome and repeat revascularization at all levels of eGFR compared with PCI.

CONCLUSIONS

Among adults with and without CKD, multivessel CABG was associated with lower risks of death and coronary events compared with multivessel PCI.

Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial

BACKGROUND

We report the 5-year results of the SYNTAX trial, which compared coronary artery bypass graft surgery (CABG) with percutaneous coronary intervention (PCI) for the treatment of patients with left main coronary disease or three-vessel disease, to confirm findings at 1 and 3 years.

METHODS

The randomised, clinical SYNTAX trial with nested registries took place in 85 centres in the USA and Europe. A cardiac surgeon and interventional cardiologist at each centre assessed consecutive patients with de-novo three-vessel disease or left main coronary disease to determine suitability for study treatments. Eligible patients suitable for either treatment were randomly assigned (1:1) by an interactive voice response system to either PCI with a first-generation paclitaxel-eluting stent or to CABG. Patients suitable for only one treatment option were entered into either the PCI-only or CABG-only registries. We analysed a composite rate of major adverse cardiac and cerebrovascular events (MACCE) at 5-year follow-up by Kaplan-Meier analysis on an intention-to-treat basis. This study is registered with ClinicalTrials.gov, number NCT00114972.

FINDINGS

1800 patients were randomly assigned to CABG (n=897) or PCI (n=903). More patients who were assigned to CABG withdrew consent than did those assigned to PCI (50 vs 11). After 5 years' follow-up, Kaplan-Meier estimates of MACCE were 26·9% in the CABG group and 37·3% in the PCI group (p<0·0001). Estimates of myocardial infarction (3·8% in the CABG group vs 9·7% in the PCI group; p<0·0001) and repeat revascularisation (13·7%vs 25·9%; p<0·0001) were significantly increased with PCI versus CABG. All-cause death (11·4% in the CABG group vs 13·9% in the PCI group; p=0·10) and stroke (3·7%vs 2·4%; p=0·09) were not significantly different between groups. 28·6% of patients in the CABG group with low SYNTAX scores had MACCE versus 32·1% of patients in the PCI group (p=0·43) and 31·0% in the CABG group with left main coronary disease had MACCE versus 36·9% in the PCI group (p=0·12); however, in patients with intermediate or high SYNTAX scores, MACCE was significantly increased with PCI (intermediate score, 25·8% of the CABG group vs 36·0% of the PCI group; p=0·008; high score, 26·8%vs 44·0%; p<0·0001).

INTERPRETATION

CABG should remain the standard of care for patients with complex lesions (high or intermediate SYNTAX scores). For patients with less complex disease (low SYNTAX scores) or left main coronary disease (low or intermediate SYNTAX scores), PCI is an acceptable alternative. All patients with complex multivessel coronary artery disease should be reviewed and discussed by both a cardiac surgeon and interventional cardiologist to reach consensus on optimum treatment.

FUNDING

Boston Scientific.

Long-term mortality of coronary artery bypass graft surgery and stenting with drug-eluting stents

BACKGROUND

Few studies have examined differences in long-term mortality between coronary artery bypass graft surgery and stenting with drug-eluting stents (DES) for multivessel disease without left main coronary artery stenosis. This study compares the risks of long-term mortality between these 2 procedures during a follow-up of up to 5 years.

METHODS

Patients who underwent isolated bypass surgery (n=13,212) and stenting with DES (n=20,161) between October 2003 and December 2005 in New York State were followed for their vital status through 2008. To control for treatment selection bias, bypass and stenting patients were matched on age, number of diseased coronary vessels, presence of proximal or nonproximal left anterior descending (LAD) artery disease, and propensity of undergoing bypass surgery. Five-year survival rates for the 2 procedures were compared and hazard ratios for death of bypass surgery compared with stenting were obtained.

RESULTS

The respective 5-year survival rates in the 8,121 pairs of matched bypass and stenting patients were 80.4% and 73.6% (p<0.001), and the risk of death after bypass surgery was 29% lower than for stenting (hazard ratio = 0.71, 95% confidence interval: 0.67 to 0.77, p<0.001). Significantly lower risks of death for bypass surgery were observed in patients with LAD artery disease but not in patients without LAD artery disease. Significantly lower risks of death for bypass surgery were also found in all patient subgroups defined by the presence of selected baseline risk factors.

CONCLUSIONS

Bypass surgery is associated with lower risk of death than stenting with DES for multivessel disease without left main stenosis.

Drug-eluting stents in multivessel coronary artery disease: cost effectiveness and clinical outcomes

Multivessel coronary artery disease is more often treated either with coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) with stenting. The advent of drug-eluting stent (DES) has changed the revascularization strategy, and caused an increase in the use of DES in multivessel disease (MVD), with reduced rate of repeat revascularization compared to conventional bare metal stent. The comparative studies of DES-PCI over CABG have shown comparable safety; however, the rate of major adverse cerebrovascular and cardiac events and repeat revascularization was significantly higher with DES-PCI at long term. In diabetic patients with MVD, concern of repeat revascularization with DES-PCI is persistent. More recent, one-year economic outcomes have reported that the CABG is favored among patients with high angiographic complexity. The higher rate of repeat revascularization with DES-PCI in MVD would lead to increased economic burden on patient at long term besides bearing high cost of DES. In diabetic MVD patients, CABG is associated with having better clinical outcomes and being more cost-effective approach when compared to DES-PCI at long term.

Percutaneous Coronary Intervention in Patients with Diabetes and Multivessel or Left Main Disease—A Review

Coronary artery disease in patients with diabetes is frequently a diffuse process with multivessel involvement and is associated with increased risk for myocardial infarction and death. The role of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with diabetes and multivessel disease who require revascularization has been debated and remains uncertain. The debate has been continued mainly because of the question to what degree an increased risk for in-stent restenosis among patients with diabetes contributes to other late adverse outcomes. This article reviews outcomes from early trials of balloon angioplasty versus CABG through later trials of bare-metal stents versus CABG and more recent data with drug-eluting stents as the comparator. although not all studies have been powered to show statistical significance, the results have been generally consistent with a mortality benefit for caBG versus PCI, despite differential risks for restenosis with the various PCI approaches. The review also considers the impact of mammary artery grafting of the left anterior descending artery and individual case selection on these results, and proposes an algorithm for selection of patients in whom PCI remains a reasonable strategy.

Changes in the safety paradigm with percutaneous coronary interventions in the modern era: Lessons learned from the ASCERT registry

In the past, comparative effectiveness trials evaluating percutaneous coronary interventions (PCI), using either balloon angioplasty or bare metal stent (BMS) implantation, versus coronary artery bypass surgery (CABG) found similar survival rates at long-term follow-up with both revascularization strategies. Two major meta-analyses of these trials reported 5- and 6-year comparative effectiveness between PCI and CABG: one included only four trials that compared PCI with BMS implantation versus CABG whereas the largest one also included trials using balloon angioplasty. In these studies, the authors observed no survival differences between groups although a significant survival advantage was seen in diabetics treated with CABG and this benefit was also perceived in elderly patients. In both reports, number of involved vessels, presence of left anterior descending artery stenosis or poor left ventricular ejection fraction were no predictors of poor survival with PCI. Therefore, extent of the coronary artery disease (CAD) was not associated with poor outcome after PCI in the pre-drug eluting stent (DES) era. Recently, the ASCERT (Database Collaboration on the Comparative Effectiveness of Revascularization Strategies) registry found higher mortality rate with PCI in patients ≥ 65 years old in comparison with CABG, and advantages of surgery were seen in all subgroups including those at low risk. In this registry, PCI was accomplished by implantation of the first type of DES designs in 78% of cases. The intriguing observation of high mortality rate with PCI, including for non-diabetics and patients with two-vessel CAD, meaning a lack of clinical benefit with DES implantation, had not been seen previously. The study was not randomized, although its results are largely strengthened by its sample size. In this manuscript, the authors describe other registries and randomized trials reporting similar results supporting the findings of the aforementioned study and explore the reasons for these results, while also searching for potential solutions.

Percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in the treatment of diabetic patients with multi-vessel coronary disease: a meta-analysis

Diabetes is prevalent in patients with coronary artery disease. In diabetic patients with multi-vessel coronary disease, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are widely used for revascularization. We aimed to compare the effectiveness and safety of PCI and CABG in these patients. Nine randomized controlled trials were identified in which a total of 1047 diabetic patients were randomly assigned to PCI and 1054 to CABG. Results showed that five-year mortality was significantly higher in diabetic patients after PCI than after CABG (risk difference (RD) of 7%; P<0.001); repeated revascularization was more common after PCI than after CABG (one-year RD of 13%; P<0.001); major adverse cardiac and cerebrovascular events were also more frequent after PCI (one-year RD of 12%; P<0.001); however, the cerebrovascular accident rate was lower in the PCI group than the CABG group (one-year RD of -2%; P=0.004). Conclusively, in diabetic patients with multi-vessel coronary disease, CABG was not only more effective than PCI in reducing mortality but also led to fewer repeated revascularizations and fewer major adverse cardiac and cerebrovascular events. Despite these benefits, CABG did put diabetic patients at higher risk for cerebrovascular accident than PCI.

Revascularization for left main and multivessel coronary artery disease in the drug-eluting stent era: integration of recent drug-eluting stent trials

As older patients comprise a greater proportion of the population, the incidence of multivessel and left main coronary artery disease is increasing. Given the improvements in percutaneous coronary intervention, more patients are suitable for this revascularization strategy. However, the optimal revascularization strategy remains a moving target. Numerous trials, extending from the bypass surgery versus medical therapy era to the most current drug-eluting stent versus bypass surgery era, provide information to select the most appropriate revascularization strategy. The objective of this review is to summarize these data.

Comparative effectiveness of revascularization strategies

BACKGROUND

Questions persist concerning the comparative effectiveness of percutaneous coronary intervention (PCI) and coronary-artery bypass grafting (CABG). The American College of Cardiology Foundation (ACCF) and the Society of Thoracic Surgeons (STS) collaborated to compare the rates of long-term survival after PCI and CABG.

METHODS

We linked the ACCF National Cardiovascular Data Registry and the STS Adult Cardiac Surgery Database to claims data from the Centers for Medicare and Medicaid Services for the years 2004 through 2008. Outcomes were compared with the use of propensity scores and inverse-probability-weighting adjustment to reduce treatment-selection bias.

RESULTS

Among patients 65 years of age or older who had two-vessel or three-vessel coronary artery disease without acute myocardial infarction, 86,244 underwent CABG and 103,549 underwent PCI. The median follow-up period was 2.67 years. At 1 year, there was no significant difference in adjusted mortality between the groups (6.24% in the CABG group as compared with 6.55% in the PCI group; risk ratio, 0.95; 95% confidence interval [CI], 0.90 to 1.00). At 4 years, there was lower mortality with CABG than with PCI (16.4% vs. 20.8%; risk ratio, 0.79; 95% CI, 0.76 to 0.82). Similar results were noted in multiple subgroups and with the use of several different analytic methods. Residual confounding was assessed by means of a sensitivity analysis.

CONCLUSIONS

In this observational study, we found that, among older patients with multivessel coronary disease that did not require emergency treatment, there was a long-term survival advantage among patients who underwent CABG as compared with patients who underwent PCI. (Funded by the National Heart, Lung, and Blood Institute.).

Improving results for coronary artery bypass graft surgery in the elderly

OBJECTIVES

The proportion of elderly patients undergoing isolated coronary artery bypass grafting (CABG) surgery has steadily increased. We have evaluated temporal trends in hospital outcomes of patients who were 75 years and older undergoing CABG (1990-2010) at our institution.

METHODS

Data were collected prospectively for 3483 consecutive patients who were 75 years and older (median 78 years; range 75-94) undergoing isolated CABG at our institution over three time cohorts: 1990-96 (n = 817), 1997-2003 (n = 1534) and 2004-10 (n = 1132).

RESULTS

Overall mortality declined from 6.0% (49/817) in the earliest era (1990-96) to 1.9% (22/1132) in the most recent era (2003-10; P < 0.001). Mortality in low-risk patients (elective, primary surgery with the ejection fraction >40%) was 5.9% (13/220), 0.8% (4/514) and 0% (0/411) in the first, second and third eras, respectively (P < 0.001). Despite the overall increase in comorbidities in our elderly patients, the prevalences of certain risk factors such as poor LV function, urgency of surgery and reoperation have all declined with time. The independent risk factors for mortality in our population were congestive heart failure, left main disease, earlier year of operation, reoperation, preoperative myocardial infarction, cardiopulmonary bypass time, emergent/urgent surgery and peripheral vascular disease. Of these, earlier year of operation (OR: 3.0; 95% CI: 1.8-5.2) was the most significant predictor. Also, age >80 did not predict mortality.

CONCLUSIONS

The principle finding from this analysis is a contemporary low operative mortality for CABG in an elderly patient cohort. Risk of death is particularly low in a low-risk subset of elderly patients with reasonable LV function undergoing elective, primary CABG.

CABG in 2012: Evidence, practice and the evolution of guidelines

Abstract: In the management of coronary artery disease (CAD) it is important to ensure that all patients are receiving optimal medical therapy irrespective of whether any intervention, by stents or surgery, is planned. Furthermore it is important to establish if a proposed intervention is for symptomatic and/or prognostic reasons. The latter can only be justified if there is demonstration of a significant volume of ischaemia (>10% of myocardial mass). Taking together evidence from the most definitive randomized trial and its registry component (SYNTAX), almost 79% of patients with three vessel CAD and almost two thirds of patients with LMS disease have a survival benefit and marked reduction in the need for repeat revascularisation with CABG in comparison to stents, implying that CABG is still the treatment of choice for most of these patients. This conclusion which is apparently at odds with the results of most previous trials of stenting and surgery but entirely consistent with the findings of large propensity matched registries can be explained by the fact that SYNTAX enrolled ‘real life’ patients rather than the highly select patients usually enrolled in previous trials. SYNTAX also shows that for patients with less severe coronary artery disease there is no difference in survival between CABG and stents but a lower incidence of repeat revascularisation with CABG. At three years, SYNTAX shows no difference in stroke between CABG and stents for three-vessel disease but a higher incidence of stroke with CABG in patients with left main stem disease. In contrast the PRECOMBAT trial of stents and CABG in patients with left main stem disease showed no excess of mortality or stroke with CABG in comparison to stents in relatively low risk patients. Finally the importance of guidelines and multidisciplinary/heart teams in making recommendations for interventions is emphasised.

An Overview on Coronary Heart Disease (A Comparative Evaluation of Turkey and Europe) and Cost-effectiveness of Diagnostic Strategies

OBJECTIVE

Coronary heart disease (CHD) is the leading cause of death for men and women in Turkey as it is in Europe and US. The prevalence of the disease is 3.8% in Turkey and 200,000 patients are added to the pool of CHD annually Because of genetic predisposition and high proportions of physical inactivity, smoking habit, and obesity, CHD is encountered in earlier ages in our country So, the economic burden of the disease is expected to be relatively high, but the amount of health expenditure is not always parallel to the prevalence of a disease in the community. This article was written to overview CHD statistics to make a comparison between Turkey and some European countries and to investigate the value of myocardial perfusion scan (MPS) as a gatekeeper in diagnosing CHD before invasive coronary angiography (ICA). The consequences were evaluated for Turkey In diagnosis; noninvasive testing gains importance in connection with the new approaches in treatment strategies, because a direct ICA strategy results in higher rates of revascularization without improvement in clinical outcomes. A "gatekeeper" is needed to select the patients who are not required to undergo angiography. MPS with its proved power in diagnosis and predicting prognosis, provides a cost-effective solution, and is accepted in some extensive analyses as a "gatekeeper" particularly in intermediate and high risk patients and in patients with known CHD. In conclusion, MPS may provide an optimal solution better than the ongoing situation in Turkey as well, when it is approved as a "gatekeeper in an algorithm before ICA.

CONFLICT OF INTEREST

None declared.

Impact of incomplete surgical revascularization on survival

Complete revascularization is considered superior to incomplete revascularization (IR), with better long-term survival and a lower rate of reintervention. However, it has yet to be established whether this difference is due directly to IR as a surgical strategy or whether this approach is merely a marker of more severe coronary disease and more rapid progression. We believe that IR is a prognostic marker for a more complex coronary pathology, and adverse effects are probably due to the preoperative condition of the patient. In fact, although IR may negatively affect long-term outcomes, it may be, when wisely chosen, the ideal treatment strategy in selected high-risk patients. IR can derive from a surgical strategy of target vessel revascularization, where the impact of surgery is minimized to reduce perioperative mortality and morbidity, aiming to achieve the best feasible safe revascularization.

Choosing a revascularization strategy in patients with diabetes and stable coronary artery disease: a complex decision

Diabetes mellitus is associated with well-known increases in cardiovascular morbidity and mortality. In diabetics with stable coronary artery disease, the best therapeutic option is widely discussed. Current studies comparing surgical to percutaneous revascularization have been unable to definitely demonstrate any significant advantage of one strategy over the other regarding the prevention of cardiac death or acute myocardial infarction. Therefore, even taking into account clinical and angiographic information as well as the risks determined by each type of treatment, the decision regarding the best therapeutic strategy in diabetics with stable coronary artery disease is still complex.